A professional organization representing physicians. The AMA publishes and maintains the CPT coding manual

A doctor of medicine (MD) or doctor of osteopathy (DO) whose specialty is to administer anesthesia during surgery

CPT codes that are included in the main body of the CPT coding manual (i.e. codes from the Evaluation and Management, Anesthesiology, Surgery, Radiology, Pathology/Laboratory, Medicine sections)

CPT codes located after the Medicine section of the CPT coding manual, which may be used to track performance management (Note: We will not be using Category II code this semester.)

A list of temporary codes used to identify "emerging technologies" in medicine. Category III codes are located before Appendix A in the CPT book (Note: Category III codes are not used in this course.)

An advanced practice nurse who may administer anesthesia during the surgery

A type of radiology procedure whereby the computer generates a cross-section ( slice) image

An Evaluation and Management service where a physician is asked to evaluate a patient at the request of another physician. The consulting physician renders a recommendation and/or opinion to the requesting physician regarding the diagnosis and/or course of treatment.

A radiopaque substance injected before a radiology procedure to provide contrast between the organ/structure, thus, providing visualization of the structure

(CPT) A medical coding system used to report procedures and services provided by physicians and other qualified health professionals. CPT is also used to code hospital services and procedures provided to outpatients.

A non-sharp removal of a skin lesion done by chemical, cold (cryosurgery), laser, electrosurgery, etc.

A definition found in the Evaluation and Management guidelines which states that a patient who has received services from a physician or another physician in the same specialty and same group practice within the past three years is considered an established patient for coding purposes.

(E&M) A section of the CPT coding manual that contains codes used by physicians to report office visits, hospital visits, preventative care, emergency room encounters, inpatient and outpatient consultations, etc.

A sharp removal of a skin lesion done with a scalpel or other sharp instrument

Visualization of moving body structures whereby a continuous x-ray is passed through the body and the images captured on a monitor

The pages preceding a section of the CPT coding manual that includes the definitions and instructions pertaining to the codes from that specific section of the book

The portion of the history report documented by a physician that describes the patient's current illness. Per the CPT coding book, the seven elements of the history of present illness are: location, severity, quality, context, modifying factors, associated signs and symptoms, and timing.

An alphabetical listing of terms/abbreviations in the back of the CPT book which points a person to the location of a code and its description in the body of the book

(history, examination and decision making) Documentation of the patient's history, examination and the physician's medical decision making must be considered in determining the level of Evaluation and Management code that is appropriated to assign.

(also called a laboratory profile) A grouping of multiple related lab tests which are done to aid in the diagnosis of a specific disease or condition

(conscious sedation) A state induced by the administration of drugs which blocks pain and allows the patient to relax during a medical procedure. The patient is able to respond to verbal commands.

Two characters that may be added to the end of a CPT code to indicate that a procedure or service identified by a CPT code was changed, but that the code description still applies. A list of CPT modifiers are provided in Appendix A of the CPT book.

A definition found in the Evaluation and Management guidelines which states that a patient who has not received services from a physician or another physician of the same specialty in the same group practice within the past three years is considered a new patient for coding purposes.

A system of names or terms use in science to identify something. CPT is an example of a nomenclature.

Scanned images taken after administration of a radioactive material

An Evaluation and Management service which is used when a patient is registered as in "observation status", (i.e. a period of typically 24 hours in which the physician determines if the patient is ill enough to require inpatient admission)

1) A patient encounter in which the patient's reason for presenting oneself is to stay healthy (also referred to as well care). 2) An encounter where a patient does not have a chief complaint.

The portion of the history report documented by the physician that represents the answers to questions the physician has asked the patient to identify information about the patient's signs/symptoms. The physician will often document this subjective data by body system.

A designation found with the description of a CPT surgery code. This designation indicates that the surgical procedure is usually consider integral or part of a larger, more complex surgical procedure and would not be coded separately. However, when done independent of a larger, more complex procedure, the code designated as a "separate procedure" may be coded.

A definition of the services typically included in the code for a surgical procedure. Services related to a surgical procedure and included in the "package" may not be coded in addition to the code for the surgical procedure.

An image produced by the use of high-frequency sound waves